implementation of an ed passive tracking system using a ... · – product overview. edtracker...
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Implementation of an ED Passive Tracking System Using a Business
Process Approach
Business Process DevelopmentImplementationEffects Analysis
Linda Laskowski Jones RN, MS, APRN, BC, CCRN, CENVice President: Emergency, Trauma & Aeromedical Services
Christiana Care Health SystemWilmington, Delaware
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Christiana Hospital• Large regional referral center in Delaware
(ranked 21st among top 25 ED’s in U.S. for patient volume)
• Level I Adult & Pediatric Trauma Center• Multiple residency programs, including EM
and surgery• Licensed for 780 Beds• ED Census >94,500 visits• Trauma Census >2,700 admissions
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Christiana Hospital Baseline State
• 55 +/- treatment bays in 5 “core” areas in 2004 (now 76 treatment rooms)
• Frequent overcrowding-- at times 40-50 patients at triage and in waiting room
• Patients hard to find (physical location)• Overall state of the ED very hard to
determine, let alone manage
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Project Description: EDTracker ™• Design of business process & installation of a
passive input using infrared technology to provide real-time tracking of both patients & ED Staff to enable:
– Rapid determination of patient status and location
– Elapsed wait time at various stages in care– Historical record of patient/staff contact (safety)– Interface with lab and radiology results– Enhanced communication with other areas
relative to ED activity and need
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• Patients & staff assigned an infrared badge; Critical equipment also tagged & tracked.
• Infrared readers installed in the ED ceiling only in clinical areas; patient movement is tracked as the patient moves under the sensors.
• Staff interaction with patients is captured.
• System visually maps ED to show patient location.
• Interfaces with lab & radiology allow results tracking
EDTracker ™ – Product Overview
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EDTracker Patient Badge with Plastic Backing
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EDTracker Staff Badge
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EDTracker Infrared Sensor
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EDTracker Spreadsheet View
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Where is the patient?• During peak periods, volume exceeds capacity• Patient tracking via the HIS bed assignment
system was manual and error prone (only accurate 70-80% max)
Who needs to know where the patient is?• ED staff: doctors, nurses, clerical and tech’s.• Hospital staff: clinical, ancillary and escort.• Outside: family/friends, physicians, clergy, law
enforcement.Patients can become “lost” in the ED!
Business Drivers
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Emergency Department Readiness
• Overall ED acuity level was very difficult to determine.
• Overview of current ED capacity & demand on that capacity was hard to assess.
• Accurate projection of required inpatient beds difficult.
• The capability to react to external emergency or disaster situations can be slowed by gaps in the above information.
Business Drivers (continued)
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Departmental Length of Stay• Overall LOS was well above norms (4-6 hours).
– Reduced LOS improves ED throughput.
– Excessive LOS contributes to suboptimal patient satisfaction & increased risk of adverse events.
Leave Without Being Treated• Lost opportunity of ~ 3500 visits and $630,000 in
revenue/year due to LWOT patients (FY 2004)
Business Drivers (continued)
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Patient/Staff Interactions• Risk to staff safety from infectious disease, lethal
agents or a bioterrorism event – unable to identify all care providers who may have had contact.
• Unable to accurately respond to complaints about clinical service (who saw the patient, when, for how long).
Lab and Rad Results • Delays in determining order status and results.
• Process inefficiencies due to printing results.
Business Drivers (continued)
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Process and Capability• Opportunities offered through use of EDTracker:
• Staff safety (staff encounter tracking for infectious agent / contaminant prophylaxis and follow-up as needed)
• Visual clues that drive work flow efficiencies to increase patient throughput
• Inter-departmental communication and work flow (bed management, patient transport, ancillary services) to improve care / patient safety
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Scope
• Tracking for all emergency patients and ED staff
• Interfaced with registration (HIS then Cerner)
• Interfaced with laboratory and radiology
• Improved communication with bed access personnel with EDAdmit and patient escort staff to facilitate transport
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Project Implementation Overview
Business process analysis: Define current and future state flow, integrating EDTracker™
Involve both front-line staff and high-level project decision makers in brainstorming sessions to plan process changes
Decide what you want your world to look like with the capabilities of the new technology (very time consuming – 30 hours)
Be willing to champion change & fix dysfunctional systems!
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• Federal bioterrorism grant proposal to support purchase 11/03; secured 2/04
• Executive approval: 4/04• Steering committee formed: 6/04
• Business processes defined: 7/04 – 9/04
• Hardware installation: 08/04
• Software and interface testing: 10/04
• ED Staff education (4 hours/session – all MD / RN / clerical & tech staff): 10/04
• Christiana Hospital ED Go-Live: 11/9/04
Project Timeline
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ResultsED Census vs. Length of Stay for Patients
Treated & Released from Core
5000
5500
6000
6500
7000Ja
n-04
Feb-
04
Mar
-04
Apr
-04
May
-04
Jun-
04
Jul-0
4
Aug
-04
Sep
-04
Oct
-04
Nov
-04
Dec
-04
Jan-
05
Feb-
05
Mar
-05
Apr
-05
May
-05
Jun-
05
# E
D p
atie
nts
3:00
3:30
4:01
4:32
5:03
5:34
Ave
rage
LO
S (h
:mm
)
Volume LOS Trtd & Rlsd Pts Linear (Volume) Linear (LOS Trtd & Rlsd Pts)
ED average LOS (time from triage to exit ED) decreased by 14 minutes post-implementation. During that same period, the volume of patients treated & released from the ED Core increased by > 7%
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Median Composite Visit, Discharged Patient, March vs June 2005
0.69
1.13
0.5
0.48
2.09
2.3
0.25
0.25
0 1 2 3 4 5
June
March
Time waiting out front Time waiting in RoomPhysician workup Dispo to Left ED
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ResultsPercent of Patients who Left without Treatment
3.7%4.1% 4.1%
3.8%4.1% 4.0%
4.5%
3.5%4.0%
3.4%2.9%
1.9%
2.6%
3.3% 3.4% 3.6% 3.4%
0.0%
1.0%
2.0%
3.0%
4.0%
5.0%Jan-0
4
Feb-0
4
Mar-
04
Apr-
04
May-0
4
Jun-0
4
Jul-04
Aug-0
4
Sep-0
4
Oct-
04
Nov-0
4
Dec-0
4
Jan-0
5
Feb-0
5
Mar-
05
Apr-
05
May-0
5
Pre-Tracker % LWOT = 3.9%
Post-Tracker % LWOT = 3.0%
24% decrease in percent of patients who LWOTLWOT rate is monitored to help promote access to
treatment and enhance patient safety
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Results
ED length of stay (time from triage to exit ED) decreased by 36 minutes post-implementation, although the volume of patients in the ED increased
ED Census vs. Length of Stay for Admitted Patients
6000
6400
6800
7200
7600
8000
8400Ja
n-0
4
Fe
b-0
4
Ma
r-0
4
Ap
r-0
4
Ma
y-0
4
Jun
-04
Jul-
04
Au
g-0
4
Se
p-0
4
Oct
-04
No
v-0
4
De
c-0
4
Jan
-05
Fe
b-0
5
Ma
r-0
5
Ap
r-0
5
Ma
y-0
5
Jun
-05
# E
D p
atie
nts
3:00
4:00
5:00
6:00
Ave
rag
e L
OS
(h
:mm
)
Volume LOS Admitted Pts Linear (Volume) Linear (LOS Admitted Pts)
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ESI Level Admit Percent ED LOS (Hours)
1 71 1.4
2 62 4.1
3 34 4.6
4 8 3.1
5 <2 2.3
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Median Composite Visit, Admitted Patient, Pre-Implementation vs
March and June 2005
0.2
0.8
1.5
0.5
0.5
0.5
2.45
2.7
2.6
0.5
1.75
3.1
1.2
1.16
1.1
0 2 4 6 8 10
June CY
March CY
Mar-04
Time waiting out front Time waiting in RoomPhysician workup Bed Request to AssignBed Assn to Left ED
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Christiana HospitalED Patient Satisfaction
70
72
74
76
78
80
82
84
FY05
JulAugSepOctNovDecJan
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• Enhanced communication with Bed Board, Admitting, Patient Escort, Radiology
• Improved communication: patients, physicians, & families re: patient location & process of care
• Eliminated clinical & operational risk due to “lost” patients.
• Objective ability to know acuity level & resource demand in ED at any given time
• Ability to anticipate inpatient bed demand via predictive capabilities of ESI triage acuity
• New data for PI & research
Other Operating Goals Achieved
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Other Operating Goals Achieved• Regulatory: Achieve a state of preparedness to
deal with all emergency situations– Decision Support Tool:
• Staff encounter summary for contamination/ infectious agents available
• Quick sort by acuity in emergency & mass casualty events (ESI triage acuity levels displayed in EDTracker™)
• ED Staff satisfaction high: No nursing vacancies!
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Next Steps• Optimize reporting capability• Real Time Dashboard
– React Quickly if the System gets out of control• Modest “upstream” interventions may well
prevent downstream chaos– Develop Decision Support Rules
• Automatic is better than human/voluntary• e.g. call for radiology support automatically
if control rules are violated